Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westminster Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
Deteriorated and Unsafe Facility Environment: The surveyor observed extensive wall damage, gouged countertops, peeling and missing wall material, cracked floor tiles, deteriorated caulking, bowing ceiling tiles, rusted vents, a loose electrical outlet still in use, and cluttered room conditions that were not homelike. The Maintenance Director stated the facility had been without maintenance staff for months, there was no formalized system to identify and address environmental issues, and the NHA acknowledged awareness of the concerns.
The facility failed to provide required transfer notices for two residents who were sent to the hospital/ER. For one resident, the record showed a hospital transfer but no documentation that the resident or RP received the required notice, and for another resident transferred for generalized weakness and critically low sodium, the chart showed family notification but no written transfer notice. The DON confirmed that written transfer notices had not been provided.
Medication error rates were not kept below the required threshold when 3 errors were found in 26 medication pass opportunities, for a 12% error rate. A RN failed to administer ordered meds to three residents because the meds were unavailable or still awaiting pharmacy delivery, and did not attempt to obtain them from the unit med room, alternate storage, or Pyxis. The DON acknowledged concerns about omitted resident meds and noted a known issue with pharmacy delivery.
QAPI failed to identify, implement, and sustain corrective action for an ongoing pharmacy medication availability problem. A resident with multiple spinal conditions and significant pain reported that ordered meds were sometimes unavailable for several days, and the DON confirmed the facility had experienced the same pharmacy delivery issue for at least two years, with little improvement despite prior citation. The NHA confirmed the issue had been discussed in QAPI and a plan to change pharmacy providers was documented, but the problem was not carried forward for continued monitoring after the plan was noted.
A resident's Entry tracking record and admission MDS were not encoded and transmitted within required timeframes. Record review showed the records were completed on paper, but the MDS data was entered into the software late after access became available during a change of ownership, resulting in delayed encoding and transmission.
A resident with dementia, behavioral concerns, and suicidal ideation had a care plan that did not identify the resident’s primary language or provide resident-specific communication interventions. Staff used a language line, Google Translator, and Spanish-speaking staff, but the plan only included a generic language-line instruction. The resident’s call bell had been removed due to behavioral concerns, yet the care plan did not document the removal or include alternative ways for the resident to request assistance.
Failure to Hold Required Care Plan Meeting: A resident did not have the required quarterly care plan meeting after an MDS assessment was completed. The resident reported that care plan discussions sometimes focused on meds rather than preferences, and record review showed the last documented meeting was months earlier. The SW, who was responsible for scheduling care plan meetings, confirmed no meeting had been held since the prior documented session and said the MDS was missed on the scheduling calendar.
Omitted Ordered Medications During Medication Pass: During a medication pass, a RN failed to administer ordered meds to three residents because the meds were unavailable or awaiting pharmacy delivery. One resident missed Peridex for oral hygiene, another missed fluoxetine for depression, and a third missed Clozaril for schizoaffective disorder. The RN did not check the med room, other storage areas, or Pyxis, and the DON acknowledged ongoing issues with timely pharmacy delivery.
Failure to provide scheduled showers to a dependent resident. A resident who relied on staff for most self-care needs stated he/she had not received a shower in 2 years and wanted regular showers. Although the unit schedule called for 2 showers per week, GNA documentation mostly showed bed baths and only one documented refusal, with no evidence the resident was consistently offered the scheduled showers. The DON said the resident consistently refused showers, but the record did not support that claim.
A resident with chronic spinal pain and another resident with ESRD on dialysis did not consistently receive ordered meds and treatments. MAR/TAR review showed multiple missed or undocumented doses and assessments, including pain meds, topical treatments, monitoring, hydralazine, and dialysis shunt checks. The DON confirmed the omissions and stated that absent documentation meant the meds or treatments were not provided.
A resident with a Stage 3 sacral PU was observed without an accessible call bell and lying on an air mattress that was actively alarming, deflated, and set to an inappropriate 1000-lb weight setting. The resident stated they were in pain, and record review showed a physician order for the air mattress to be set per manufacturer guidelines every shift; the DON acknowledged the concern.
Medication orders were not consistently available for dispensing to a resident with multiple spinal conditions and significant pain. The resident reported that the pharmacy was often out of medications and that it sometimes took several days for meds to become available. The DON confirmed ongoing problems with the pharmacy provider’s timely delivery of ordered meds, and MAR review showed gaps in administration documentation, including an instance where ordered Tizanidine was not given because it was out of stock/not available.
A resident’s monthly MRR identified multiple meds with anticholinergic effects and duplicate statin therapy, but the MD responses documented only “MD not in agreement” without a clinical rationale. The resident continued receiving trazodone, meclizine, hydroxyzine, dicyclomine PRN, Benadryl, pravastatin, and simvastatin, and the DON stated she was unaware that a rationale was required when declining the pharmacist’s recommendations.
Meal Tray Did Not Match Resident Preferences: A resident’s lunch tray did not match documented food preferences. The tray was prepared with double portions of the entree even though the resident had requested no longer receiving double portions, and it was missing yogurt even though the resident had requested yogurt with meals. The dietary manager stated staff had grabbed the wrong tray.
Food was not served in an appetizing condition or at proper hot-holding temperatures. Multiple residents reported cold, bland, and terrible-tasting meals, and during kitchen observation staff did not check steam table temperatures before trays were prepared. A test tray showed dry parmesan noodles, bland spinach, and hot foods well below the dietary manager’s stated 135-degree F holding standard.
Improper Food Labeling and Storage: During a kitchen observation, surveyors found multiple food items in the freezer and refrigerator without required labels showing when they were opened or their use-by dates. Items included chicken patty, bologna, pineapple, pudding, brown beans, and pureed chicken, and staff acknowledged the labeling concerns.
Failure to Follow EBP During Feeding Tube Care: A resident with a feeding tube had a physician order for enhanced barrier precautions during hands-on care and when accessing the enteral tube site. A surveyor observed an RN administer meds via the tube, provide flushes, and perform tube site care without wearing a gown, despite the posted EBP sign indicating gown use was required. The RN stated she thought EBP meant hand hygiene and gloves for dressing care, and noted no gowns were available outside the room.
Inaccessible Resident Call Bell: A resident was observed in pain, but the call bell was not within reach and could not be located. The surveyor had to use the empty bed call bell to get staff assistance, and an RN later found the resident's call bell behind the head of the bed.
A resident was not protected from abuse when a GNA slapped the resident on the buttocks twice while providing incontinence care. The incident was substantiated through the resident’s consistent statements, corroborating interviews, and confirmation that a witness GNA’s involvement aligned with the resident’s account, demonstrating that the resident was not kept free from physical abuse by staff.
Staff failed to promptly report an allegation of abuse and to submit investigation results within required timeframes. A resident, who believed they had a BM and used the call bell, was assisted by two GNAs; one allegedly slapped the resident’s bare buttocks twice and made a dismissive comment after finding no BM, while the other GNA witnessed the event but did not notify administration. The resident later disclosed the incident to another GNA, who reported it to administration, resulting in the allegation being reported to the State Survey Agency more than two hours after it was witnessed and the final investigative report being submitted more than five working days after the incident.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to lapses in safeguarding measures.
A resident with intact cognitive function reported missing several pairs of sweatpants, and despite notifying staff, the grievance was not resolved within the facility's required timeframe. Documentation showed incomplete follow-up and a lack of resolution, with staff interviews revealing unclear roles and insufficient action in addressing the resident's complaint.
A resident reported missing money from a locked nightstand drawer, and the facility's investigation was incomplete, lacking statements from all relevant staff shifts. The DON acknowledged that not all necessary staff were interviewed, resulting in insufficient documentation of the incident.
Licensed nursing staff documented the administration of an eye drop medication for a resident before the medication was delivered to the facility. Despite pharmacy delivery delays, several doses were signed off as given in the eMAR, and this was confirmed through interviews with an LPN and the DON, as well as a review of the medication audit trail.
A medical provider did not review or renew a resident's pain medication order, resulting in the discontinuation of as-needed Oxycodone for a resident with chronic pain. The provider later acknowledged the order's expiration was an error, and the DON confirmed the lack of review at the time. The resident experienced a lapse in pain management until the medication was reordered.
A resident with complex medical and psychiatric conditions experienced a delay in receiving prescribed eye drops for a new onset of eye redness, as the facility was waiting for pharmacy delivery over several days. Nursing staff and the DON confirmed ongoing issues with timely medication delivery from the pharmacy, requiring repeated follow-up and escalation.
A resident with neurological and psychiatric diagnoses was ordered eye drops for a change in eye condition. The eMAR showed that the drops were documented as administered by three nurses before the medication was actually delivered to the facility. Interviews and record audits confirmed the medication was not available at the time of documentation, resulting in incomplete and inaccurate medical records.
A resident with severe cognitive impairment and chronic pain was administered both tramadol and oxycodone, despite a physician's order to discontinue tramadol upon the arrival of oxycodone. This oversight occurred due to nurses overlooking the order, leading to the resident receiving both medications and subsequently exhibiting stroke-like symptoms.
The facility failed to report a suspected abuse incident involving a resident to the state agency within the required two-hour timeframe. The incident occurred in the resident's room, and although the facility's policy aligns with federal requirements for timely reporting, the report was submitted four hours after the incident. The DON confirmed the delay during an interview.
The facility failed to investigate a missing Oxycodone blister pack from a medication cart and did not document or interview involved staff. Additionally, an allegation of verbal abuse by a GNA was not investigated after a resident reported it via email to the administrator.
A resident did not receive a baseline care plan (BLCP) summary within 48 hours of admission, as required. The BLCP, essential for ensuring continuity of care and communication among staff, was not documented as provided to the resident. The DON confirmed the lack of documentation and emphasized the BLCP's role in guiding safe and accurate care from admission.
A resident with two pressure ulcers, one facility-acquired, did not have a person-centered care plan addressing mobility and skin integrity. The care plan lacked interventions for when the resident refused repositioning and did not include specific wound care interventions. The DON confirmed the absence of individualized care plans for the resident's needs.
A facility failed to meet a resident's personal hygiene needs, as they did not document or provide necessary assistance with activities of daily living. The resident, requiring maximum assistance due to medical conditions, reported inadequate cleaning and removal of their commode chair, impacting their dignity. Interviews revealed a lack of specific interventions to consistently meet the resident's needs.
The facility failed to notify the family of a deceased resident about the remaining balance in the resident's account within the required 30-day timeframe. The Business Office Manager confirmed that the notification was sent late, only the day before the survey.
A resident's medical information was left visible on an unlocked laptop screen on a medication cart in a hallway, unattended by an LPN. The LPN confirmed the screen should have been locked, and the DON stated that staff are expected to lock screens when away.
A facility failed to update a resident's care plan to reflect changes in their behavioral issues and refusal of nursing interventions. The resident, requiring maximum assistance with ADLs, expressed concerns about the removal of their commode chair, inadequate cleaning, and delayed staff responses. Despite these issues, the care plan was not revised to address the resident's reluctance to get out of bed or use a motorized wheelchair. The deficiency was discussed with the DON during the survey.
A medication cart was found unlocked and unattended in a hallway, contrary to the facility's policy. An LPN confirmed the cart was left unlocked, and the DON stated that carts should be locked when unattended.
The facility failed to maintain infection control practices, as evidenced by an uncapped Foley catheter drainage bag, unlabeled urinals without lids, and brown matter on a commode. Staff interviews revealed that urinals should be stored in residents' drawers and labeled, and cleaning supplies are accessible to nursing staff. Despite these protocols, the deficiencies indicate lapses in infection control.
The facility failed to adhere to professional standards in managing controlled medications, with discrepancies in narcotic counts and improper signing off by LPNs. Issues included mismatched pill counts, damaged medication packs, and missing signatures during shift changes. Staff interviews revealed non-compliance with facility policies for narcotic management.
The facility failed to ensure adequate kitchen staffing, affecting all residents. Observations and staffing schedules revealed consistent understaffing, with many shifts having fewer than the required 1 cook and 3 culinary aides. The facility assessment did not identify the necessary food and nutrition services staff needed.
The facility failed to monitor food temperatures, follow sanitary practices, store food properly, maintain dishwasher temperatures, and ensure an adequate food supply. Observations included incomplete temperature logs, unsanitary conditions, improper food storage, and insufficient milk supply. Interviews with staff confirmed these deficiencies.
The facility failed to employ a qualified social worker on a full-time basis. The Activities Director had been providing social work services since November 2023, despite not being a qualified social worker. The NHA confirmed that the facility, with a capacity of more than 120 beds, had not employed a full-time social worker since the previous one left at the end of January 2024.
The facility failed to meet at least quarterly to conduct required QAPI activities. Review of sign-in sheets revealed no QAPI meetings were held in November and December 2023 or January 2024. The NHA acknowledged the lapse and noted an Ad Hoc QAPI meeting was held in February 2024 to address the issue.
The facility failed to include dietary staffing in their facility-wide assessment, leading to inadequate kitchen staffing and operational issues. A staff member, originally in maintenance, was observed working as a culinary aide, and the Dietary District Manager was unfamiliar with the assessment. The facility assessment did not identify food and nutrition services staff needed, which was confirmed by the Administrator.
The facility failed to revise and update comprehensive care plans within seven days after completing assessments and did not hold timely care plan meetings with residents and/or their representatives. This deficiency was identified for five residents during the recertification survey.
The facility failed to address and review medical orders pending provider signature, provide timely care for residents with a change in condition, and arrange timely follow-up post-op visits. This affected multiple residents, leading to potential duplicate medication administration, delayed interventions for declining conditions, and missed follow-up appointments.
Two residents experienced delays in the uploading of medical records, including psychotherapy notes and consults, which were not documented within the facility's expected 72-hour timeframe. One resident's Acute Visit note was signed after the resident had already been transferred to a hospital, making it unavailable for review during a critical period.
A Geriatric Nursing Assistant (GNA) dragged a resident backwards on a shower chair through the hallway due to a broken footrest, failing to treat the resident with respect and dignity.
Facility staff failed to notify a resident's representative and physician of a diet change and new medication. The resident's diet was changed to dysphagia puree, and cough medication was prescribed without proper documentation or notification. Staff interviews revealed communication and documentation lapses.
The facility failed to inform and assist residents with establishing advance directives, as evidenced by the lack of documentation and conflicting responsibilities among staff. Interviews with staff confirmed the deficiency, highlighting a systemic issue in the facility's process.
Deteriorated and Unsafe Facility Environment
Penalty
Summary
The facility failed to ensure that the environment remained safe, clean, comfortable, and homelike. During the initial tour, the surveyor observed extensive deterioration throughout the second and first floors, including thinning, worn, chipped, and gouged walls; a large area of peeling and missing wall material outside one room; and a countertop in one room with two deep gouges. In a bathroom, the wall showed prior water damage that had been painted over with ridging and bubbling, the ceiling tiles were bowing and misaligned, the heating vent was rusted with chipped paint, the floor tiles were cracked, and the caulking was worn, deteriorated, and peeling away. The room also lacked a chair for visitors, and part of the room contained a partially pulled curtain enclosing a bed without a mattress, a wheelchair, and bedside tables, creating a cluttered appearance. Another room had a gouged door with wide black marks and missing tiles around the pipe under the sink. In a separate room, an electrical outlet was loose and falling out of the wall while still in use, and the walls behind both beds had deep gouges that had been painted over without proper repair. The Maintenance Director stated he had started about one month earlier after the position had been vacant for several months and said he was responsible for plumbing, electrical work, repairs, and overall maintenance. He acknowledged that there were numerous areas needing attention, that he had needed to prioritize urgent issues, and that there was no formalized log or systematic process in place at the time to ensure environmental issues were identified and addressed. He also confirmed the surveyor’s concerns during a joint tour, including the damaged walls, missing tiles, bowing ceiling tiles, gouged countertops, missing chair, deteriorated caulking, and unsafe electrical outlet. The Nursing Home Administrator also confirmed awareness that the facility had been without maintenance staff for a period and acknowledged the environmental concerns after reviewing photographs of the issues.
Failure to Provide Required Transfer Notice
Penalty
Summary
The facility failed to provide a transfer notice to residents who were transferred out of the facility. For Resident #2, the medical record showed the resident was transferred to the hospital on 3/20/26, but review of the record did not reveal documentation that the required transfer notice information was provided to the resident or the responsible representative. When the concern was reviewed with the DON, additional documentation was provided, including a Hospital Transfer Form, but it still did not show that the required transfer notice information had been given. For Resident #105, progress notes showed the resident was transferred to the emergency room on 3/27/26 for generalized weakness and a critically low sodium level based on lab results, and a family member was notified of the transfer. However, the medical record did not contain evidence that a written transfer notice had been provided to the resident or representative. A bed-hold policy signed by a family member and a transfer packet were later provided, but neither contained a written transfer notice, and the DON confirmed that a written transfer notice had not been provided.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
Medication error rates were not kept below 5 percent. During a medication administration observation on 4/30/26 with a Registered Nurse, 3 errors were identified out of 26 opportunities, for an error rate of 12%. The observation included Residents #13, #32, #103, and #49, and the errors involved medications that were not administered as ordered for 3 of the 4 residents observed. Resident #103 did not receive Peridex Mouth/Throat Solution 0.12% 15 ml by mouth twice daily for oral hygiene because Staff #3 stated it was not available and that a refill request had been sent to the pharmacy. Resident #49 did not receive FLUoxetine HCl 10 mg, 3 capsules by mouth daily for depression because the medication was not available; a progress note also documented a missed dose on 4/27/26 for the same reason. Resident #32 did not receive Clozaril 25 mg by mouth in the morning for schizoaffective disorder because Staff #3 stated pharmacy delivery was still being awaited. During the observation, Staff #3 did not attempt to escalate the unavailable medications, obtain them from the unit medication room, alternative storage areas, or the Pyxis. The DON later acknowledged concerns about omitted resident medications and stated there was a known issue with pharmacy services delivering medications to the facility.
QAPI Failed to Sustain Monitoring of Ongoing Pharmacy Medication Availability Issue
Penalty
Summary
The facility failed to ensure that its QAPI program identified, implemented, and sustained corrective actions for an ongoing systemic problem involving the unavailability of ordered medications from the pharmacy provider. Resident #11, who reported multiple spinal conditions and significant pain, stated that staff were generally timely with medication administration but that the pharmacy was often out of medications and it sometimes took several days for medications to become available. The resident described repeated frustration with the pharmacy supply issue and said the medications were not consistently available when needed. The DON confirmed that the facility had experienced ongoing problems with timely medication delivery from Pharm Script for at least two years and stated that the facility had previously been cited for the same issue. The DON reported that the pharmacy had promised to hire additional drivers, but there had been little to no improvement and resident medication orders continued to go unfilled. The NHA confirmed awareness of the issue and stated the facility was in the process of changing pharmacy providers, but she also found that the issue had been discussed in QAPI in September 2025 and that a plan to implement a new pharmacy provider by the end of the year was documented in October 2025. She further confirmed that the issue was not carried forward for continued monitoring after October 2025, despite no evidence that the corrective action had been completed or that the problem had been resolved.
Late MDS Encoding and Transmission for Admitted Resident
Penalty
Summary
The facility failed to complete and submit MDS assessments for an admitted resident within the required timeframes. Record review showed that Resident #110 was admitted to the facility, but the continued review did not initially show a completed Entry tracking record or an admission MDS in the electronic health record. A later review identified an Entry tracking record dated 4/3/26 that was completed and transmitted on 4/30/26, which was 20 days late for encoding and 13 days late for transmission. Further review found an admission MDS dated 4/7/26 and signed as completed on 4/8/26 in Section V0200C2. The MDS should have been encoded by 4/15/26 and transmitted electronically by 4/22/26, but staff #8 entered the data into the facility's MDS software on 4/30/36, 22 days after V0200C2 was completed and 8 days late for transmission. During interview, staff #8 stated the facility was undergoing a change of ownership and did not have access to the MDS software from April 1-10, and said she completed the Entry tracking and admission MDS on paper but did not enter the data when access became available.
Failure to Individualize Care Plan for Communication Needs and Call Bell Removal
Penalty
Summary
The facility failed to ensure that Resident #78 had a personalized, resident-specific care plan. During the initial screening, the resident was observed speaking a language that appeared to be a mix of Italian and Spanish, and there was no call bell present in the room. A review of the care plan later showed that it did not identify the resident’s primary language and did not include individualized interventions to guide staff on how to communicate effectively with the resident. The care plan also did not document the resident’s communication needs or preferences. The care plan included a general language-line intervention that instructed staff to press 1 for Spanish, press 2 for all others and clearly state the language, or press 0 if the language was unknown, but it did not identify the resident’s language or provide resident-specific direction. The DON stated that Resident #78 had dementia and a history of behavioral concerns, including self-inflicting behaviors such as banging head and expressed suicidal ideation without a specific plan. The DON also stated that the resident spoke Spanish and very little English, that staff used a language line, Google Translator, and Spanish-speaking staff to communicate, and that the call bell had been removed because of behavioral concerns and suicidal ideation. The care plan did not reflect the resident’s primary language, the removal of the call bell, or interventions for increased monitoring or alternative methods to request assistance.
Failure to Hold Required Care Plan Meeting
Penalty
Summary
The facility failed to hold required care plan meetings for one resident reviewed for care planning. Resident #37 stated during interview that care plan meetings might occur, but also said that discussions sometimes happened about medications and not about the resident’s preferences. Review of the resident’s care plan meeting sign-in sheets showed that the most recent documented care plan meeting was on 12/4/25, and no additional documentation was found to show that another meeting had been held after that date. Further record review showed that an MDS assessment was completed and submitted in February 2026, but there was no evidence that a care plan meeting was conducted within the required timeframe after that assessment. The facility Social Worker, who stated she was responsible for scheduling all care plan meetings, reviewed the documentation and confirmed that no care plan meeting had been conducted since 12/4/25. She stated that the February 2026 MDS had been completed earlier than expected and was not captured on her scheduling calendar, which led to the failure to schedule and conduct the required meeting.
Omitted Ordered Medications During Medication Pass
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice by not administering ordered medications for 3 of 4 residents observed during a medication pass. During observation on the first floor with a RN, Resident #103 did not receive Peridex Mouth/Throat Solution 0.12% ordered 15 ml by mouth twice daily for oral hygiene because the medication was not available, and the RN stated the pharmacy had been notified of the refill request. Resident #49 did not receive FLUoxetine HCl 10 mg, ordered as 3 capsules by mouth daily for depression, because the medication was not available; the medical record also showed a progress note from 4/27/26 documenting the medication was not administered that day because it was unavailable. Resident #32 did not receive Clozaril 25 mg, ordered 1 tablet by mouth in the morning for schizoaffective disorder, because the RN stated it was awaiting pharmacy delivery. During the observation, the RN did not attempt to obtain the medications from the unit medication room, alternative medication storage areas, or the automated dispensing system (Pyxis). The DON acknowledged concerns about omitted resident medications and stated the issue was known to be related to pharmacy services delivering medications in a timely manner. The DON also stated that while the facility kept some medications in stock, the omitted medications were not commonly stocked in Pyxis, and there was no evidence that alternative measures were implemented to ensure the residents received the medications as ordered.
Failure to Provide Scheduled Showers to a Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who required assistance with ADLs received showers. Resident #23 stated during interview that he/she had not received a shower in 2 years and wanted to shower regularly. The resident’s MDS indicated that he/she did not walk and relied on staff for most self-care needs. The shower schedule for the unit showed the resident was scheduled for showers on Wednesdays and Saturday evenings, totaling 8 showers per month. A review of GNA shower documentation from December 2025 through April 30, 2026 showed one resident refusal and four bed baths in December, four bed baths in January, five bed baths in February, seven bed baths in March, and five bed baths in April. The documentation did not show that the resident was consistently offered 2 showers per week. The DON stated that the resident was to be offered showers twice a week and that refusals were to be reported and documented, but also stated that the resident consistently refused showers, without providing evidence that the resident consistently refused them.
Missed ordered medications and treatments for residents with pain and dialysis needs
Penalty
Summary
The facility failed to ensure that medications and treatments were provided as ordered for a resident with multiple spinal conditions and significant ongoing pain. The resident reported that pain medications were not always received as ordered. Review of the March 2026 MAR and TAR showed multiple dates with no documentation that ordered medications and treatments were administered, including vital signs monitoring, aspirin, lidocaine patches, mirtazapine, tizanidine, Voltaren, Biofreeze, gabapentin, pain monitoring, respiratory/COVID-19 symptom screening, oxycodone, atorvastatin, multivitamin, pantoprazole, Senokot, vitamin C, ferrous sulfate, fluticasone propionate, anxiety monitoring, anticoagulant side effect monitoring, antidepressant side effect monitoring, and wearing a back brace when out of bed. The DON confirmed the documentation gaps and stated that when documentation is absent, it indicates the medications or treatments were not provided. The facility also failed to consistently administer ordered medications and treatments for a resident with renal failure and end-stage kidney disease who attended dialysis three times per week. Review of the April 2026 MAR and TAR showed missed doses of hydralazine, ordered every 8 hours for hypertension including on dialysis days, and missing dialysis shunt assessments intended to verify the presence of a thrill or bruit. The DON confirmed that hydralazine was not administered on two dates and that the shunt assessments were not documented on three dates. The resident reported having kidney failure and receiving dialysis three times weekly, and the care plan reflected the diagnosis and dialysis-related interventions.
Failure to Maintain Ordered Pressure-Relieving Mattress and Accessible Call Bell
Penalty
Summary
The facility failed to ensure implementation of physician-ordered pressure-relieving interventions and proper functioning of a pressure-reducing device for Resident #47, who had diagnoses including a Stage 3 pressure ulcer of the sacral region. During observation, the resident motioned for the surveyor to enter the room, but the call bell was not within reach and could not be located. The resident was lying on a pressure-reducing air mattress that was actively alarming, and the mattress was deflated with the resident appearing to be lying on the bed frame. The resident also stated they were in pain at that time. A record review showed a physician order dated 2/18/25 for an air mattress to the bed with settings per the manufacturer's guidelines every shift. At the time of observation, the mattress was not set according to the manufacturer guidelines, as shown by an inappropriate weight setting of 1000 pounds, and the device was alarming without timely correction. During interview, the DON acknowledged the concern related to the failure involving pressure ulcer prevention for the resident.
Medication Orders Not Available for Dispensing
Penalty
Summary
The facility failed to ensure that ordered medications were available for dispensing to a resident who reported multiple spinal conditions and significant pain. During an interview, the resident stated that staff were generally timely with medication administration, but that the pharmacy was often out of medications and it sometimes took several days for medications to become available. Review of the resident’s February, March, and April 2026 MARs showed multiple gaps in medication administration documentation, and the reason for those gaps could not be determined from the record review. The DON stated that the facility had experienced ongoing problems for at least two years with timely medication delivery from the pharmacy provider, Pharm Script, and that the pharmacy continued to fail to fulfill resident medication orders. She stated that nurses were instructed to document a 9 on the MAR when a medication was not administered because it was unavailable and to contact the pharmacy, but also confirmed that residents did not receive the medication until it became available. As an example, documentation showed that the resident did not receive ordered Tizanidine on 4/25/26 because it was out of medication/not available. The NHA also confirmed awareness of the ongoing pharmacy delivery issues and stated the facility was in the process of transitioning to a new pharmacy provider.
Physician Responses to Pharmacist Medication Review Lacked Clinical Rationale
Penalty
Summary
The facility failed to ensure that physicians documented a clinical rationale when declining pharmacist recommendations during the monthly medication regimen review process. For Resident #113, a pharmacist identified multiple medications with anticholinergic effects, including trazodone, meclizine, hydroxyzine, dicyclomine PRN, and Benadryl, and recommended review for possible dose reduction or alternatives with less cholinergic effects. The physician response documented only that the MD was not in agreement, with no clinical rationale provided in the record. A second pharmacist recommendation identified duplicate statin therapy, noting that Resident #113 was receiving both pravastatin and simvastatin and recommending discontinuation of one. The physician again documented only MD not in agreement without supporting rationale. Review of the MAR showed the resident continued to receive trazodone, meclizine, hydroxyzine, dicyclomine, Benadryl, pravastatin, and simvastatin as of the survey date. The DON stated she entered MD not in agreement and filed it, and acknowledged she was not aware that a rationale was required when a physician declined a pharmacist recommendation.
Meal Tray Did Not Match Resident Preferences
Penalty
Summary
The facility failed to serve a resident meals that reflected the resident’s preferences. During a lunch tray line observation, a test tray prepared for the resident was supposed to include Italian sausage, sautéed spinach, Parmesan noodles, a buttered dinner roll, margarine, spiced peaches, 4 oz yogurt, and 8 oz fruit punch, with double portions of the entree. The tray that was inspected contained the entree items, roll, margarine, peaches, and fruit punch, but did not include the 4 oz yogurt listed on the meal slip. Record review showed that the resident had a dietitian’s note dated 1/9/26 stating the resident requested no longer receiving double portions of entrees and breakfast meats, with the change noted in the diet order and Meal Tracker. Another dietitian’s note dated 1/15/26 documented that the resident wanted yogurt with meals, also noted as updated in Meal Tracker. Despite these documented preferences, the lunch meal slip observed earlier still showed double portions of the entree, and the tray served did not include the yogurt. In interview, the dietary manager stated the staff had grabbed the wrong tray for the resident.
Food Served at Improper Temperature and Poor Quality
Penalty
Summary
Food and drink were not served in a palatable, attractive, and safe appetizing temperature. During resident interviews at initial screening, multiple residents reported that the facility's food was served cold and tasted bland and terrible. During kitchen observation, the cook was preparing lunch items and had already begun adding food to the steam table, including sausage, dinner rolls, spinach, and parmesan noodles. Before trays were prepared for the units, staff failed to check the temperatures of the food items on the steam table to determine the holding temperatures of the hot foods. On a test tray prepared for a resident on a regular diet with double portions of the entree, the parmesan noodles were dry and the sauteed spinach was bland and flavorless. The sausage measured 83.4 degrees F and the spinach measured 114.6 degrees F, while the dietary manager stated that the acceptable holding temperature for hot foods on the tray line should be 135 degrees F.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards during a kitchen observation in the recertification survey. In the walk-in freezer, surveyors observed 3 slices of chicken patty in a zip-lock bag with no label showing when it was opened or its use-by date. In the walk-in refrigerator, surveyors observed 3 slices of bologna in a zip-lock bag with no label indicating when it was opened or its use-by date, chunks of pineapple in a container labeled "use by 4/22" that staff said was a labeling mistake and was actually the prepared date, butter scotch pudding labeled "use by 4/25" that staff said was also a mistake and represented the opening date rather than a use-by date, prepared brown beans labeled "use-by 4/18" that staff said should have been the prepared date and still needed a use-by date, and pureed chicken with no label showing the prepared date or use-by date. Staff acknowledged the concern about not labeling food items.
Failure to Follow Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
The facility failed to ensure staff maintained physician-ordered enhanced barrier precautions while providing care to a resident who received medications and feedings through a feeding tube. The resident had an order in effect since 4/25/25 to use enhanced barrier precautions when providing hands-on care or accessing the enteral tube site. The facility policy stated that enhanced barrier precautions include hand hygiene and targeted gown and glove use during high-contact resident care activities, including accessing or using a feeding tube. On 5/1/26 at 8:33 AM, a surveyor observed a nurse access the resident’s feeding tube to administer three medications, provide water flushes before and after each medication, and then clean the tube entry site and apply a clean gauze dressing. The nurse did not wear a gown during the medication administration or tube site care. When asked about enhanced barrier precautions, the nurse stated that it meant cleaning hands and using gloves for the dressing, and acknowledged the gown requirement was missed. The nurse also stated she had asked whether any residents were on precautions that morning and was told no, and noted there was no supply of gowns outside the resident’s room. The DON later stated the gowns were located on the door inside the room.
Inaccessible Resident Call Bell
Penalty
Summary
The facility failed to ensure that a resident call system was within reach and readily accessible for Resident #47. During observation, the resident motioned for the surveyor to enter the room and stated they were in pain, but the resident's call bell was not within reach and could not be located. Because the call bell was inaccessible, the surveyor used the empty bed call bell to alert staff. A registered nurse later entered the room in response, was informed that the resident's call bell could not be found, and then located it behind the head of the bed. The nurse retrieved the call bell and secured it to the resident's blanket, and the Director of Nursing later acknowledged the concern regarding the inaccessible call bell.
Failure to Protect a Resident From Physical Abuse During Incontinence Care
Penalty
Summary
Facility staff failed to protect a resident from physical abuse by a Geriatric Nursing Assistant (GNA). According to the facility’s investigation of a reported incident, on one evening after dinner and before 11:00 PM, during incontinence care, the resident was slapped on the buttocks twice by a GNA. The allegation of physical abuse was substantiated based on the resident’s statements, repeated interviews that produced a consistent recounting of the incident, and confirmation from police that a witness GNA’s involvement matched the resident’s consistent statements. The Director of Nursing acknowledged these findings during discussion with surveyors. This deficiency centers on the occurrence of physical abuse during the provision of incontinence care, as verified by the victim’s account and corroborating witness information, demonstrating that the resident was not kept free from abuse while under the care of the involved GNA.
Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
Facility staff failed to immediately report an allegation of abuse to facility administration and the State Survey Agency and failed to submit the results of the investigation within the required timeframe. The incident involved a resident who believed they had a bowel movement and activated the call bell. Two GNAs responded; after determining the resident had not had a bowel movement, one GNA allegedly slapped the resident’s bare buttocks twice and made a remark implying the resident was “just playing.” This alleged abuse was witnessed by the second GNA, who did not notify facility administration at the time of the incident. The resident later reported the alleged abuse to another GNA, who then informed facility administration. The facility documented the incident as having occurred on a specific date and reported it to the State Survey Agency more than two hours after the alleged abuse was witnessed. Additionally, the facility’s final self-report of the investigation was submitted to the State Survey Agency more than five working days after the incident. The DON was informed of concerns regarding staff failure to report the witnessed abuse promptly and the late submission of the final self-report and acknowledged these concerns.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe environment for all residents. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Resolve Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to maintain an effective grievance system as evidenced by its handling of a complaint regarding missing clothing for a resident. The resident, who was assessed to have intact cognitive function with a BIMS score of 14 out of 15, reported missing four pairs of sweatpants and stated that facility staff had not taken any action after being informed. The Director of Nursing (DON) acknowledged being aware of the complaint and documented the grievance, noting the specific items missing and that some clothing had been found while others remained unaccounted for. However, the section of the grievance form designated for resolution was left blank, and there was no documented resolution within the facility's stated timeframe for resolving grievances. Interviews with facility staff revealed a lack of clarity and follow-through in the grievance process. The Social Worker described her role as collecting grievances and distributing them to the appropriate staff, but indicated that missing items concerns were directed to the Administrator. Despite the facility's policy requiring grievances to be resolved within a reasonable timeframe, generally within five business days, the complaint regarding the missing clothing remained unresolved at the time of the survey. The Administrator confirmed that the grievance had not been resolved and acknowledged the need for process improvement.
Incomplete Investigation of Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to provide documentation that allegations of misappropriation of property were thoroughly investigated for one resident. The incident involved a resident who reported that money was missing from a locked nightstand drawer, which appeared to have been broken into. The resident was unsure of the exact time the theft occurred but believed it happened during the night while they were watching TV in the dining room. The facility's investigation included written statements from four out of five night shift staff and three out of eight evening shift staff, but did not include statements from the day shift staff who worked the following morning. During an interview, the DON confirmed that the investigation was incomplete, acknowledging that statements from all relevant staff, particularly those on the evening shift, were not obtained. The resident's account of the incident was noted to be inconsistent, but the lack of comprehensive staff interviews and documentation resulted in an incomplete investigation of the alleged misappropriation.
Medication Administration Documented Prior to Receipt
Penalty
Summary
Licensed nursing staff failed to meet professional standards of practice by documenting the administration of a medication before it was actually available in the facility. Specifically, a resident with multiple diagnoses, including cerebral infarction with hemiplegia, aphasia, and psychiatric disorders, was ordered to receive Polyethylene glycol eye drops for redness and dryness in the left eye. The medication was ordered and documented as not given on the first scheduled dose, with a corresponding note explaining the delay due to pharmacy delivery. However, subsequent doses were signed off as administered by nursing staff, despite the medication not being delivered to the facility until several days later. Interviews with the LPN who signed off on the administration and the DON confirmed that multiple nurses documented the medication as given when it had not yet been received. The audit trail in the electronic medical record verified that the medication was not dispensed to the facility until after the dates it was documented as administered. The NHA was made aware of the issue and acknowledged the concern during the surveyor's investigation.
Failure to Review and Renew Pain Medication Orders
Penalty
Summary
A medical provider failed to appropriately review and manage pain medication orders for a resident with chronic pain due to trauma. The resident was admitted with an order for Oxycodone 15 mg every 4 hours as needed for pain, which was subsequently reduced in dosage and frequency by the nurse practitioner responsible for pain management. The Oxycodone order was eventually set to expire after 21 days, and upon expiration, the medication was discontinued without a documented review or renewal by the provider. The resident had not received the as-needed Oxycodone for a period following the discontinuation, despite ongoing reports of pain. The nurse practitioner acknowledged during interview that the 21-day limitation on the Oxycodone order was an error and that the medication should have been ordered indefinitely until a formal reevaluation occurred. The DON confirmed that the provider did not review the resident's medication orders at the time the Oxycodone order expired. The resident later reported that the discontinued as-needed medication had been effective in controlling pain, which was no longer managed after the discontinuation until the order was eventually reinstated.
Failure to Provide Timely Physician-Ordered Medications Due to Pharmacy Delays
Penalty
Summary
The facility failed to provide physician-ordered medications in a timely manner to meet the needs of a resident. A resident with multiple diagnoses, including cerebral infarction with hemiplegia and hemiparesis, aphasia, generalized anxiety disorder, bipolar disorder, and major depressive disorder, was admitted in May 2024. On July 17, 2025, a change in condition was noted when the resident developed redness in the left eye, and a new order for Polyethylene glycol eye drops was prescribed. Documentation in the electronic Medication Administration Record (eMar) indicated that the medication was not available and the facility was waiting for pharmacy delivery. Over the following days, additional notes confirmed that the medication had still not been delivered, and staff continued to document the delay. Interviews with the DON and nursing staff confirmed ongoing issues with the pharmacy's timely delivery of medications. The DON acknowledged repeated problems, especially on weekends, requiring escalation to corporate and personal intervention to obtain necessary medications. Nursing staff reported having to repeatedly contact the pharmacy and sometimes order medications STAT due to urgent resident needs. The NHA was also made aware of the ongoing concerns regarding medication delivery delays.
Inaccurate Medication Administration Documentation Prior to Medication Receipt
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed during a complaint survey. The resident, admitted with multiple diagnoses including cerebral infarction with hemiplegia and hemiparesis, aphasia, and several psychiatric conditions, experienced a change in condition when redness was noted in the left eye. A new order for Polyethylene glycol eye drops was placed, but documentation in the electronic Medication Administration Record (eMAR) indicated that the medication was signed off as administered on several occasions before it was actually delivered to the facility. Interviews with nursing staff and review of the medication audit details confirmed that three nurses documented administration of the eye drops prior to their arrival at the facility. The LPN involved could not recall the specifics and acknowledged the possibility of documentation error. The Director of Nursing and Nursing Home Administrator both confirmed that the medication was not available at the time it was documented as given, resulting in inaccurate and incomplete medical records for the resident.
Failure to Discontinue Medication as Ordered
Penalty
Summary
The facility failed to follow the physician's orders for a resident's medication management, leading to the administration of both tramadol and oxycodone, contrary to the physician's directive. The resident, who had severe cognitive impairment and was admitted with conditions including deep vein thrombosis and chronic pain, was prescribed tramadol for pain management. The physician ordered that tramadol be discontinued once oxycodone was delivered to the facility. However, the facility did not adhere to this order, resulting in the resident receiving both medications. On the evening of the delivery of oxycodone, a registered nurse signed for the medication but did not discontinue tramadol as required. The following morning, another nurse administered both tramadol and oxycodone to the resident, who was experiencing significant pain. This oversight was acknowledged by the nurses involved, who admitted to overlooking the order to discontinue tramadol. The resident subsequently exhibited stroke-like symptoms, prompting a hospital evaluation. The medical director reviewed the case and noted that while the resident received the lowest doses of both medications, the tramadol should have been discontinued as per the physician's order. The medical director also stated that the combination of medications was not likely to have caused the stroke-like symptoms, but emphasized that the tramadol should have been discontinued upon the arrival of oxycodone.
Delayed Reporting of Suspected Abuse
Penalty
Summary
The facility staff failed to report an allegation of suspected resident abuse to the state agency within the required timeframe. The incident involved a resident and occurred in the resident's room at approximately 11:45 AM. The facility's policy and federal requirements mandate that such allegations be reported to the state agency within two hours. However, the initial report was sent at 3:47 PM, exceeding the two-hour window. During an interview, the Director of Nursing confirmed the procedure for reporting alleged abuse and acknowledged that the report was submitted late, four hours after the incident was reported to the facility's administration.
Failure to Investigate Allegations of Misappropriation and Verbal Abuse
Penalty
Summary
The facility staff failed to conduct a thorough investigation into an allegation of misappropriation of property involving a resident's medication. Specifically, a blister pack of Oxycodone was reported missing from a medication cart during a specific shift. The investigation lacked critical documentation, including the staffing sheet and an interview with the nurse who completed the narcotic count with the responsible LPN. The LPN confirmed the missing narcotics were from their cart and identified the outgoing nurse involved in the narcotic count, but no statement from this nurse was included in the investigation, and the nurse no longer works at the facility. Additionally, the facility did not investigate an allegation of verbal abuse reported by a resident. The resident had emailed the facility's administrator detailing a verbal encounter with a Geriatric Nursing Assistant, but this email was not included in the documents reviewed by the surveyor. The administrator confirmed that no investigation was conducted regarding the verbal abuse allegation, indicating a failure to address the resident's concerns appropriately.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a baseline care plan (BLCP) summary to a resident within 48 hours of admission, as required. This deficiency was identified during a survey where it was found that a resident did not receive a BLCP summary, including a list of current medications, within the specified timeframe. The BLCP is crucial for ensuring continuity of care and communication among staff, as well as for increasing resident safety and preventing adverse events immediately following admission. During interviews and a review of the resident's electronic medical record, it was confirmed that there was no documentation indicating the resident had received the BLCP summary. The Director of Nursing (DON) acknowledged the absence of such documentation and reiterated the importance of the BLCP in guiding staff to provide safe and accurate care from the moment a resident is admitted. Despite the DON later providing a BLCP dated after the resident's admission, there was no evidence that the resident had been given a copy of the plan.
Failure to Implement Person-Centered Care Plan for Mobility and Wound Care
Penalty
Summary
The facility staff failed to initiate a person-centered care plan for a resident's mobility and wound care needs. During a review of the resident's electronic medical record, it was found that the resident had two pressure ulcers, one of which was acquired at the facility. The care plan lacked interventions for when the resident refused to be turned or repositioned, and there was no person-centered care plan addressing skin integrity. The care plan did not include specific interventions related to the resident's wound care and overall care needs. An interview with the Director of Nursing confirmed the absence of patient-centered care plans for the resident's mobility and skin integrity. The deficiency was identified in one of the four resident records reviewed for care plans, highlighting a failure to provide individualized care planning for the resident's specific needs.
Deficiency in Meeting Resident's Personal Hygiene Needs
Penalty
Summary
The facility failed to ensure that a dependent resident's personal hygiene needs were adequately met, as evidenced by the lack of documentation and assistance provided to Resident #2. This resident, who required maximum two-person assistance with activities of daily living due to a below-the-knee amputation, morbid obesity, and impaired mobility, did not receive documented assistance with personal hygiene during the night shift on 08.14.24. Additionally, there was no documentation of assistance with showering and bathing on multiple dates throughout August 2024. The resident expressed concerns about the removal of their commode chair, which was taken away after a fall, and reported that the GNAs did not clean their buttocks thoroughly after bowel movements, leading to discomfort and a negative impact on their dignity. Interviews with the unit manager and the director of nursing revealed a lack of specific individualized interventions to assist the resident with their ADL goals consistently. The unit manager noted that the resident often refused scheduled showers but stated that staff would try to accommodate the resident's requests for showers on other days. However, there was no evidence of consistent clinical interventions to address the resident's needs, particularly in light of their history of refusing ADL assistance. The director of nursing acknowledged the expectations for GNAs and nurses to use clinical interventions for residents with a history of refusing ADL assistance, but the facility's practices did not align with these expectations, leading to the identified deficiency.
Failure to Timely Notify Family of Deceased Resident's Account Balance
Penalty
Summary
The facility staff failed to notify the family of a deceased resident about the remaining balance in the resident's account. This deficiency was identified during a survey when the surveyor reviewed the account balances of residents' funds managed by the facility. It was found that the resident had passed away, and the notification to the family regarding the account balance was sent past the 30-day allotted timeframe. The Business Office Manager confirmed that the notification letter was sent to the family the day before the survey, which was beyond the required notification period.
Resident Information Privacy Breach
Penalty
Summary
The facility staff failed to protect the privacy of residents' medical information, as observed by a surveyor. During a survey, a laptop on a medication cart was left unlocked and open, displaying a resident's medication administration record (MAR) with prescribed medications visible. This occurred when a nurse was not present at the cart, leaving the information exposed for approximately one minute. Upon returning, the LPN acknowledged that the screen was left visible and confirmed that it should have been locked to protect resident information. The Director of Nursing stated that the facility's expectation is for staff to lock computer screens when leaving them unattended.
Failure to Update Resident Care Plan for Behavioral and ADL Needs
Penalty
Summary
The facility failed to appropriately revise the care plan for a resident as their care needs changed over time. Specifically, the care plan did not reflect the resident's current behavioral issues and refusal of nursing interventions, which were documented by a mental health nurse practitioner. The resident, who required maximum assistance with activities of daily living (ADLs), expressed concerns about the removal of their commode chair, inadequate cleaning after bowel movements, and the negative impact on their dignity due to staff's delayed response to requests. Despite these issues, the care plan was not updated to address the resident's reluctance to get out of bed or their refusal to use the motorized wheelchair. The surveyor's review of the resident's records revealed that the behavior contract and care plan had not been revised in 2024 to address the resident's current needs and behaviors. The care plan revision in August 2024 failed to include new individualized staff interventions to encourage the resident to participate in showers, out-of-bed activities, and mobility. The facility's deficient practices were discussed with the Director of Nursing during the survey and at the exit conference.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility staff failed to ensure medications were secured, as evidenced by an unlocked and unattended medication cart. This deficiency was observed by a surveyor who noted that one of the seven medication carts reviewed was left unlocked and unattended in the hallway. The surveyor observed the cart, located across from a specific room, with its locking mechanism in the unlocked position. Approximately one minute later, an LPN returned to the cart and confirmed that it had been left unlocked. The facility's Medication Administration policy explicitly states that medication carts should not be left unlocked. During an interview, the Director of Nursing confirmed that the expectation is for medication carts to be locked immediately when unattended.
Infection Control Lapses in Facility
Penalty
Summary
The facility staff failed to maintain proper infection control practices, as observed during a survey. An uncapped Foley catheter drainage bag was found hanging on the handle of the commode in a resident's bathroom. Additionally, two unlabeled urinals without lids were observed hanging over the commode in a shared bathroom between two rooms. Furthermore, brown matter was noted on the commode in another shared bathroom. These observations indicate lapses in infection control protocols, which were confirmed by a Geriatric Nursing Assistant during the survey. Interviews with facility staff revealed further insights into the deficiencies. The Infection Prevention Nurse stated that urinals should not be left in the bathroom but should be placed in a plastic bag and stored in residents' drawers, and they must be labeled. The Environmental Service Manager mentioned that rounds are conducted regularly to ensure cleanliness, with housekeepers working in shifts to maintain hygiene. The Director of Nursing confirmed that nursing staff have access to cleaning supplies if needed. Despite these protocols, the observed deficiencies suggest a failure in adhering to established infection control practices.
Deficiencies in Controlled Medication Management
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding the management of controlled medications. During a random narcotic reconciliation observation, it was found that controlled medications were not signed off by the LPN upon removal from the narcotic drawer for three residents. Specifically, discrepancies were noted in the narcotic control forms for Lorazepam and Pregabalin for one resident, and Lorazepam for another, where the number of pills in the blister packs did not match the recorded count. Additionally, Oxycodone IR for a third resident was not signed off in the narcotic book after administration. Further issues were identified with the safety and integrity of narcotic medications. A blister pack for a resident contained a Tramadol pill sealed with tape, and another resident's Acetaminophen Codeine blister pack had damaged pills that should have been wasted. The facility also failed to ensure that two nurses signed the narcotic sheet during change of shift to verify the narcotic count was complete. Several instances were noted where only one nurse signature was present on the shift count sheets, indicating a lack of proper verification. Interviews with staff revealed a lack of adherence to the facility's policy that requires narcotics to be signed off immediately when removed from the narcotic drawer. The DON acknowledged the issues and stated that the facility's policy was not followed. The nurse manager admitted to missing the signature part during audits, and the DON confirmed that the practice of not signing the narcotic logbook was unacceptable.
Inadequate Kitchen Staffing
Penalty
Summary
The facility failed to ensure adequate staffing levels in the kitchen, affecting all residents. On multiple occasions, the surveyor observed insufficient staffing, including instances where only one cook and one or two culinary aides were present after 5 PM. Staff #15, who was originally in maintenance, was observed working in the kitchen, indicating a lack of specialized kitchen staff. The food committee minutes also documented various kitchen concerns due to the lack of staff, such as the inability to call the kitchen, lack of soup or chili, and no time to make desserts or cakes. The surveyor's review of the kitchen staffing schedules from 3/1/24 to 4/4/24 revealed consistent understaffing, with many shifts having fewer than the required 1 cook and 3 culinary aides. The facility assessment failed to identify the necessary food and nutrition services staff needed. The facility Administrator and the Regional Director of Operations acknowledged the surveyor's concerns, confirming the deficiency in the facility's assessment of kitchen staffing needs.
Multiple Deficiencies in Food Service Safety and Sanitation
Penalty
Summary
The facility failed to ensure the monitoring and oversight of food temperatures in accordance with professional standards for food service safety. During the surveyor's initial tour of the kitchen, it was observed that food temperature logs were incomplete on multiple dates. Specific instances included missing temperature logs for lunch and dinner meals on several dates, and the surveyor's temperature testing of food trays revealed that the main entree was served at temperatures below the required standards. Interviews with kitchen staff confirmed that food temperatures had not been taken, and food committee minutes documented recurring complaints about cold food from residents. The facility also failed to follow sanitary practices in accordance with professional standards for food service safety. Observations included a cutting board resting against a kitchen rack wheel close to the floor, beverage device nozzles resting on the kitchen floor, and wet nesting of trays. Interviews with kitchen staff confirmed these observations, and immediate actions were taken to address the concerns. However, these practices were not in line with maintaining a sanitary kitchen environment. Additionally, the facility did not ensure that food was stored properly, as evidenced by a container of mayonnaise-based salad with a cracked lid in the walk-in refrigerator. The dishwasher also failed to reach adequate temperatures according to the manufacturer's guidelines, with documented instances of the machine not meeting the required minimum wash and rinse temperatures. Lastly, the facility's food supply order was inadequate, as evidenced by a resident's complaint about the lack of milk and the observation of a limited milk supply in the kitchen. Interviews with kitchen staff confirmed issues with food ordering and supply management.
Failure to Employ Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis, which was identified during a recertification survey. A review of the facility's list of key personnel on 4/02/24 revealed the absence of a social worker. On 4/03/24, the Activities Director confirmed that she had been providing social work services since November 2023, despite not being a qualified social worker. The Nursing Home Administrator (NHA) acknowledged in interviews on 4/03/24 and 4/12/24 that the facility, which has a capacity of more than 120 beds, did not employ a full-time social worker since the previous one left at the end of January 2024.
Failure to Conduct Quarterly QAPI Meetings
Penalty
Summary
The facility failed to meet at least quarterly to conduct required Quality Assurance and Performance Improvement (QAPI) activities. This was identified during a recertification survey. The review of QAPI sign-in sheets from November 2023 through March 2024 revealed that the facility did not hold a QAPI meeting in November and December 2023 or in January 2024. Instead, the facility provided sign-in sheets for clinical standard weekly meetings held from November 16, 2023, through January 26, 2024, which were not QAPI meetings. The Nursing Home Administrator (NHA) acknowledged in an interview that the facility did not hold QAPI meetings during this period and had an Ad Hoc QAPI meeting on February 26, 2024, to address the issue.
Failure to Include Dietary Staffing in Facility Assessment
Penalty
Summary
The facility failed to include dietary staffing in their facility-wide assessment, which is necessary to determine the resources required for competent resident care. This deficiency was identified when a surveyor observed a staff member, whose job title was maintenance, working in the kitchen as a culinary aide. The staff member reported that they had been performing various roles within the facility, including maintenance and social work, and had been working in the kitchen for the past two weeks. The staff member also indicated that on Mondays, the kitchen was staffed only by themselves and the cook. Further review of food committee minutes revealed multiple concerns related to kitchen operations, including a lack of staff leading to issues such as the inability to call the kitchen, lack of soup or chili, and insufficient time to prepare desserts or cakes. During an interview, the Dietary District Manager admitted to being unfamiliar with the facility assessment. The surveyor reviewed the facility assessment, last updated on 11/30/23, and found that it did not identify any food and nutrition services staff needed. Additionally, no food service staff were included in the assessment tool outlining persons involved in completing the assessment. The facility Administrator confirmed the omission of food and nutrition services staffing in the assessment. After the surveyor's intervention, the Administrator updated the facility assessment to include the necessary food and nutrition services staffing.
Failure to Revise Care Plans and Hold Timely Care Plan Meetings
Penalty
Summary
The facility failed to revise and update comprehensive care plans within seven days after completing comprehensive assessments and did not hold care plan meetings with residents and/or their representatives. This deficiency was identified for five residents during the recertification survey. For instance, Resident #88's care plan inaccurately included interventions for nicotine use despite the resident having quit smoking a year ago and having no active orders for nicotine products. The Nursing Home Administrator confirmed that the care plan had not been revised and was inaccurate. Resident #87's medical record revealed that a care plan meeting was not documented within seven days of the quarterly MDS assessment. The unit director confirmed the absence of documentation for a care plan meeting since the last quarterly assessment. Similarly, Resident #61's medical record did not show evidence of a care plan meeting after the quarterly MDS assessment, and the facility provided a document to a cognitively impaired individual without proper documentation of the resident's or responsible party's participation. Resident #75's care plan meetings were documented 15 and 19 days after the comprehensive assessments, respectively, which exceeded the required seven-day timeframe. Additionally, Resident #110's medical record showed that care plan meetings were held 17 days after the comprehensive assessment, and there was no documentation that the resident's representative was notified or attended the meetings. The Director of Nursing confirmed these concerns during an interview with the surveyor.
Failure to Address Medical Orders, Timely Care, and Follow-Up Appointments
Penalty
Summary
The facility failed to have a process in place to address and review medical orders pending provider signature, provide timely care for residents who experienced a change in condition, and timely arrange for a resident to go for their 2-weeks follow-up post-op visit. For Resident #46, the facility did not have a process to ensure that duplicate medication orders pending provider signature would not result in the resident receiving a duplicate dose. Staff interviews revealed that there was no system in place to prevent this, relying instead on nurse-to-nurse verbal reports, which could lead to errors if not communicated properly. This was confirmed by multiple staff members, including the Acting Unit Manager and the Infection Control Preventionist and Educator, who acknowledged the concern when it was brought to their attention by the surveyor. Resident #109 experienced a decline in condition, including difficulty chewing and sitting up unassisted, which was documented on 1/31/24. Despite abnormal lab results indicating kidney issues, there was confusion and lack of communication among staff regarding the administration of IV fluids. The CRNP was unaware that the resident had been placed on IV fluids and there was no documentation of the decision-making process. The resident was eventually transferred to the hospital on 2/3/24, but the delay in timely intervention and lack of clear communication among the interdisciplinary team contributed to the deficiency. Resident #110 had a change in condition on 2/22/24, including lethargy, slow response, and elevated pulse rate, but did not receive any interventions until being transferred to the hospital on 2/23/24. The medical record lacked documentation of any interventions for the resident's change in condition on 2/22/24. Staff interviews revealed discrepancies in the documentation, with the attending NP insisting he did not see the resident on 2/22/24 despite progress notes indicating otherwise. The Director of Nursing and other staff members acknowledged the concern when it was brought to their attention by the surveyor. Additionally, Resident #107 was unable to have a timely 2-weeks post-op follow-up visit due to scheduling issues, which were not communicated to the surgeon or the resident's family, nor documented in the medical records.
Delayed Documentation of Medical Records
Penalty
Summary
The physician/Certified Registered Nurse Practitioner (CRNP) progress notes were not written, signed, and timely present in the resident medical records. This deficiency was evident for two residents reviewed during the survey. For Resident #46, multiple instances were noted where psychotherapy visit notes, x-ray reports, and other consults were not uploaded to the medical record within the facility's expected timeframe of 72 hours. For example, a psychiatric note dated 3/15/24 was not uploaded until 3/21/24, and several other notes had similar delays. During an interview, the CRNP admitted that the documentation for weekly visits had not been uploaded to the medical record, which was confirmed by the Director of Nursing (DON) who acknowledged the provider was not in compliance with the facility's documentation policy. For Resident #109, the CRNP's Acute Visit note dated 2/1/24 was not signed until 2/4/24, by which time the resident had already been transferred to a hospital on 2/3/24. This delay meant that the CRNP's note was not available in the resident's chart for review during the critical period before the transfer. A meeting with the DON, Divisional VP of clinical services, Division VP of Clinical Assessment and Reimbursement, and the CRNP confirmed that the late note would not have been in the resident's chart for review on the necessary dates, further highlighting the issue of delayed documentation.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by an incident involving a Geriatric Nursing Assistant (GNA) and a resident. The incident occurred when the GNA dragged the resident backwards on a shower chair through the hallway from the resident's room to the shower room and back. The resident reported that the GNA could not pull them forward because their feet were dragging on the floor. The GNA confirmed that the footrest on the shower chair was broken and did not stay in place, leading to the backward dragging of the resident.
Failure to Notify Representative and Physician of Diet and Medication Changes
Penalty
Summary
Facility staff failed to notify a resident's representative party and physician when the resident had a change in diet order and a new prescribed medication. This was evident for one resident who had their diet order changed from regular to dysphagia puree and was prescribed cough medication without proper documentation or notification to the relevant parties. The resident's loved one was unaware of the diet change and the new medication until the resident was transferred to the hospital with pneumonia. Interviews with staff revealed that the speech therapist changed the diet order based on an evaluation but did not ensure the change was communicated to the nursing, dietitian, and dietary manager. Additionally, the Licensed Practical Nurse stated that all changes should be reported and documented, which did not occur in this case. The Nurse Practitioner who placed the order for the cough medication did not have a note regarding the resident's cough, and the Director of Nursing acknowledged that the process for documenting and communicating changes was not followed correctly.
Failure to Inform and Assist Residents with Advance Directives
Penalty
Summary
The facility failed to inform residents of their right to establish an advance directive and provide assistance if the resident wished to execute one or more directives. This deficiency was identified for three residents during a review of their medical records, which revealed no documentation indicating that the facility staff provided advance directive information or assistance. Interviews with facility staff, including a registered nurse, the nursing home administrator, a regional social worker, and the admission director, confirmed that there was a lack of clarity and responsibility regarding who should provide this information to residents. The registered nurse stated that providers and social workers were responsible for assisting residents with advance directives, while the regional social worker indicated that the admission department managed new residents' advance directives. However, the admission director stated that she did not handle clinical tasks, including advance directives. The nursing home administrator validated the surveyor's concerns about the lack of opportunity for residents to formulate an advance directive, highlighting a systemic issue in the facility's process for managing advance directives.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 938 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westminster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carroll Lutheran Village | 1 mi | ★★★★★ | 0 | 0 |
| Atlee Hill Health And Rehab Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Long View | 10.4 mi | ★★★★★ | 13 | 0 |
| Future Care Cherrywood | 11.2 mi | ★★★★★ | 1 | 0 |
| Copper Ridge Nursing And Assisted Living Center | 11.2 mi | ★★★★★ | 9 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.